New Hampshire - Residential Care Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

New Hampshire regulates 24-hour residential care for Medicaid Home and Community-Based Services through two primary avenues: licensure as an Assisted Living Residence-Residential Care (ALR-RC) under administrative rule He-P 804 for the Choices for Independence (CFI) waiver, or certification as a Community Residence under He-M 1001 for the Developmental Disabilities (DD) and Acquired Brain Disorders (ABD) waivers. Facilities serving four or more individuals require formal licensure through the Department of Health and Human Services (DHHS) Health Facilities Administration, while smaller adult foster care or staffed residences operate under agency certification.

To receive Medicaid reimbursement for residential services under the DD or ABD waivers, a prospective provider must secure a contract with one of New Hampshire's ten designated regional Area Agencies. The state delegates the oversight, vendor contracting, and participant service authorization entirely to these Area Agencies, meaning independent facilities cannot enroll directly with the state as standalone DD/ABD residential providers without this regional network affiliation.

1. Service Definition and Scope

In New Hampshire, residential care services are delivered in licensed or certified settings that provide 24-hour supervision, personal care, and habilitation. Under the CFI waiver, these services are typically provided in Assisted Living Residences licensed at the Residential Care (He-P 804) or Supported Residential Health Care (He-P 805) levels.

For the DD and ABD waivers, residential supports are delivered in Community Residences (He-M 1001), which include agency-operated staffed residences and family-based adult foster care homes. These settings are designed to integrate individuals into the community while meeting their specific health and safety needs.

• Assisted Living Residence-Residential Care (ALR-RC): Licensed under He-P 804 to provide personal care and supervision to individuals whose needs can be met within the facility's retention policy.
• Supported Residential Health Care (SRHC): Licensed under He-P 805, allowing for higher acuity care, including mechanical transfers and short-term 24-hour nursing monitoring.
• Community Residence: Certified under He-M 1001, typically serving 3 or fewer individuals in a family or agency-staffed home for DD/ABD waiver participants.
• Capacity Limits: Facilities with 4 or more beds must obtain formal ALR licensure from the Health Facilities Administration.

2. Regulatory and Oversight Agencies

The New Hampshire Department of Health and Human Services (DHHS) is the single state Medicaid agency and oversees all HCBS waivers. Within DHHS, the Health Facilities Administration (HFA) handles the licensure of ALRs and other health facilities.

The Bureau of Developmental Services (BDS) oversees the DD and ABD waivers, while the Bureau of Elderly and Adult Services (BEAS) manages the CFI waiver. The ten regional Area Agencies act as the designated oversight and contracting entities for DD/ABD services.

• NH DHHS Health Facilities Administration (HFA): Licenses ALR-RC and SRHC facilities (https://www.dhhs.nh.gov/programs-services/health-care/health-facilities-administration).
• NH DHHS Bureau of Developmental Services (BDS): Oversees DD and ABD waivers and Area Agencies (https://www.dhhs.nh.gov/programs-services/disability-care/developmental-services).
• NH DHHS Bureau of Elderly and Adult Services (BEAS): Administers the Choices for Independence (CFI) waiver (https://www.dhhs.nh.gov/programs-services/adult-aging-care).
• NH State Fire Marshal: Reviews and approves architectural, sprinkler, and fire alarm plans for licensed facilities (https://www.dos.nh.gov/fire-safety-and-training/state-fire-marshal).

3. Gatekeeping Prerequisites: Who Can Even Apply

The most definitive structural precondition for providing residential services under the DD and ABD waivers is the requirement to contract with a designated Area Agency. New Hampshire operates a closed regional network for these waivers; providers cannot enroll directly with DHHS as a DD/ABD residential provider without an Area Agency contract.

For CFI waiver providers seeking ALR-RC licensure, applicants must secure written local approvals (fire, health, and zoning) before submitting a licensure application to HFA. Without these local sign-offs, the state will not process the application.

• Area Agency Contracting: Mandatory prerequisite for DD/ABD waiver residential providers; must secure a vendor contract with one of the 10 regional Area Agencies.
• Local Fire Approval: Written approval from the local fire department required within 90 days prior to submitting the He-P 804 application.
• Local Health Officer Approval: Written approval from the local health officer required within 90 days prior to application.
• Zoning Approval: Written confirmation from the local zoning board or municipality that the proposed facility meets local zoning ordinances.

4. Licensure and Certification Requirements

To operate an ALR-RC, providers must submit the Application for Residential, Health Care License to the HFA, accompanied by architectural plans, local approvals, and the required fee. The facility must pass an initial life safety and health inspection by HFA surveyors.

Community Residences operating under He-M 1001 for DD/ABD waivers undergo a certification process managed by the Office of Program Support (OPS) and the contracting Area Agency, which includes site visits to ensure compliance with HCBS settings rules.

• Application Form: Must submit the HFA "Application for Residential, Health Care License or Special Health Care Services".
• Licensure Fee: $15 per licensed bed for He-P 804/805 facilities, though this fee is waived for facilities serving HCBC (HCBS) or NH State placed residents.
• Architectural Plans: Must be submitted to the State Fire Marshal's office as required by RSA 153:10-b, V, showing room designations and exact measurements.
• Secretary of State Authorization: Must provide a Certificate of Authority or Certificate of Formation proving authorization to do business in New Hampshire.

5. Medicaid Provider Enrollment

Once licensed or certified, providers must enroll in the New Hampshire Medicaid program through the NH MMIS Health Enterprise portal. Providers are subject to risk-based screening in accordance with He-W 520.06.

DD/ABD residential providers are often enrolled as atypical providers or sub-contractors under the Area Agency's umbrella, whereas CFI ALR-RC providers enroll directly as atypical or institutional providers depending on their exact billing structure.

• Enrollment Portal: NH MMIS Health Enterprise Provider Portal (https://nhmmis.nh.gov).
• Risk Categorization: Providers are screened at limited, moderate, or high risk levels per He-W 520.06, dictating the intensity of the background checks.
• Application Fee: Institutional providers may be subject to the ACA Medicaid application fee unless waived or already paid to Medicare.
• Revalidation: Enrolled providers must revalidate their Medicaid enrollment every 5 years (or 3 years for certain high-risk categories).

6. Staffing, Training and Background Checks

New Hampshire requires comprehensive background checks for all residential care staff and administrators. Under He-W 520.06 and RSA 161-F:49, this includes state and federal criminal background checks with fingerprinting, as well as checks against the BEAS State Registry.

Administrators of ALR-RC facilities must submit a resume identifying their qualifications and copies of any applicable licenses with the initial application. Staff must receive training on the facility's policies, emergency procedures, and the specific needs of the admitted residents.

• Criminal Background Check: State and federal fingerprint-based checks required for high-risk providers and owners with direct/indirect interest.
• BEAS Registry Check: Mandatory check of the Bureau of Elderly and Adult Services state registry for all staff pursuant to RSA 161-F:49.
• Administrator Qualifications: Must submit a resume and applicable licenses to HFA demonstrating competency to manage the ALR-RC.
• Conflict of Interest: Providers must report any actual or potential conflicts of interest, including employing immediate family members of DHHS employees, within 5 days.

7. Documentation, Policies and Records

Licensed ALR-RC and SRHC facilities must maintain strict documentation regarding admissions, resident rights, and service disclosures. A Department-required disclosure summary form must be provided to all applicants prior to admission.

Facilities must also maintain a clear Admission and Retention Policy. ALR-RCs may only admit and retain individuals whose needs they can safely meet, while SRHCs have broader allowances for mechanical transfers and short-term nursing care.

• Disclosure Summary Form: Mandatory form provided prior to admission detailing the base rate, included services, staff coverage, and transportation.
• Admission and Retention Policy: Written policy defining the acuity levels the facility can safely manage and evacuate.
• HCBS Settings Compliance: Documentation proving the setting integrates residents into the greater community and ensures privacy and autonomy.
• Fire Safety Plans: Approved performance-based design documentation or standard fire marshal approvals must be kept on site.

8. Billing, Rates and Claims

Billing procedures differ significantly between the waivers. CFI waiver providers bill the NH MMIS directly for authorized residential care services using specific HCPCS codes and modifiers assigned to their licensure level.

For the DD and ABD waivers, the Area Agencies manage the funding allocations and process payments to their contracted vendor agencies and community residences. The Area Agency bills the state, and the provider is paid according to their negotiated contract rate.

• CFI Billing: Claims are submitted directly to the NH MMIS Health Enterprise system for authorized ALR-RC services.
• DD/ABD Billing: Claims and payments are processed through the contracted regional Area Agency, not directly to MMIS.
• Room and Board: Medicaid HCBS funds cannot pay for room and board; these costs must be collected directly from the resident's SSI or personal income.
• Rate Setting: CFI rates are established by DHHS fee schedules; DD/ABD rates are negotiated within the participant's authorized budget via the Area Agency.

9. Approval Sequence and Timeline

The approval sequence begins at the local level. An applicant must secure local fire, health, and zoning approvals, and submit architectural plans to the State Fire Marshal. Once local approvals are in hand, the He-P 804 application is submitted to HFA.

HFA reviews the application and conducts an initial on-site inspection. Concurrently, DD/ABD providers must negotiate their contract with the regional Area Agency. Final Medicaid enrollment through MMIS occurs only after licensure/certification and contracting are complete.

• Step 1: Obtain local fire, health, and zoning approvals (must be within 90 days of HFA application).
• Step 2: Submit architectural plans to the State Fire Marshal for approval.
• Step 3: Submit the HFA licensure application with the $15/bed fee (if applicable) and background check results.
• Step 4: Pass the HFA initial life safety and health inspection.
• Step 5: (DD/ABD only) Finalize vendor contract with the regional Area Agency.
• Step 6: Submit Medicaid enrollment application via NH MMIS Health Enterprise.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to incomplete local approvals or failure to submit architectural plans to the State Fire Marshal prior to applying. HFA will not process applications missing the required municipal sign-offs.

During surveys, common citations include retaining residents whose acuity exceeds the facility's licensed retention policy (especially in He-P 804 facilities lacking SRHC status), incomplete BEAS registry checks for new hires, and failure to meet HCBS settings rule requirements for community integration.

• Missing Local Approvals: Application rejected if fire, health, or zoning letters are older than 90 days or missing.
• Retention Policy Violations: Cited for keeping residents who require 24-hour nursing or mechanical lifts in a standard ALR-RC.
• Background Check Gaps: Failure to complete the BEAS registry check prior to a staff member's first day of direct contact.
• Fire Code Deficiencies: Failure to accurately show room designations and measurements on submitted architectural plans.

11. Key Contacts and Resources

Prospective providers should utilize the DHHS website to access current administrative rules (He-P 804, He-M 1001) and licensure applications. The NH MMIS portal provides enrollment guides and billing manuals.

For DD/ABD services, providers must contact the specific Area Agency covering their target geographic region to initiate the contracting process.

• DHHS Health Facilities Administration: https://www.dhhs.nh.gov/programs-services/health-care/health-facilities-administration
• NH MMIS Health Enterprise Portal: https://nhmmis.nh.gov
• Bureau of Developmental Services (Area Agency Directory): https://www.dhhs.nh.gov/programs-services/disability-care/developmental-services
• NH State Fire Marshal: https://www.dos.nh.gov/fire-safety-and-training/state-fire-marshal

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